HomeMy WebLinkAbout49772-Z TOWN OF SOUTHOLD
' It "w BUILDING DEPARTMENT
a�
` TOWN CLERK'S OFFICE
ro „' SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE, SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 49772 Date: 9/22/2023
Permission is hereby granted to:
O'Hara, William
265 E 66th St#2G
New York NY 10065
To: construct additions and alterations to existing single-family dwelling as applied for.
At premises located at:
165 Ro ers Rd, Southold
SCTM # 473889
Sec/Block/Lot# 66.-2-22
Pursuant to application dated 9/22/2023 and approved by the Building Inspector.
To expire on 3/23/2025.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $501.60
CO -ADDITION TO DWELLING $50.00
Total: $551.60
Bui ing 'nspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1 179 Southold, NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 I?tlpL/Avvya .s utholdi+o"yv`MV. "o1v
Date Received
APPLICATION FOR BUILDING PERMIT
10 LE ffl-71 1-71
For Office Use Only
Li
PERMIT N0. Building lnspectors-� ""
Applications and forms must be filled out in their entirety. Incomplete `
applications will not be accepted. Where the Applicant is not the owner,an
IRLTILDL, 1C
Owner's Authorization form(Page 2)shall be completed. TOWN OF SO
Date:08/29/22
OWNER(S)OF PROPERTY:
Name:Karen O'Hara SCTM # 1000-66-2-22
Project Address: 165 Rogers Road Southold NY 11971
Phone#:917-804-8005 Email:karenpedlow@me.com
Mailing Address:165 Rogers Road Southold NY 11971
CONTACT PERSON:
Name: Michelle Sarabia AMP Architect r
Mailing Address:12-@@4*r"1=K Mattituck NY 11952
P
none#:631-603-9092 Email:msarabia@amparchitect.com
DESIGN PROFESSIONAL INFORMATION:
Name:Anthony Portillo AMP Architecture
Mailing Address.: Mattituck NY 11952
Phone#:631-603-9092 _ Email:aportillo@amparchitect.com
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
::]New Structure FAddition Alteratl n ❑Repair :]Demolition Estimated Cost of Project:
,-IOther $
Will the lot be re-graded? ❑Yes W No Will excess fill be removed from premises? ❑Yes *No
1
PROPERTY INFORMATION
11'1 1 n ii d" Intended use of property:si ry�U Far n,19 &S i don
Existing use of property: 5� � y J
Zone or use district in which premises is situated: Are there any covenants grad restriction with respect to
this property?
(]Yes 9io IF YES, PROVIDE A COPY.
by
Citlidl
a:dC , Ii ox Aftilir Reading: The owner/contractor/desiprprofessional is responsible for ad drainage and stonnwater�as the deli
Bu ng zone
Chapter 236 of the Town Code.APPUCAT10N IS HEREBY MADE to the Building Department IssngrMs or uance ofBuild'' t the construction o buildings,
additions,
aloha Town of r removal
Suffolk,County,New York and other e l agrees
to cornply wM all applicable laws,ordirmues,building rode,
addttlons,akaatbrrs or for romoval or demoRtlon as haefrr described.The a Fait �made herein arc
housing code and regulations and to admit authorized Inspectors on premises and In building(s)for necammY inspections.
punishable as a Class A misdaneanor pursuant to section 210AS of the New York State Penal law.
Application Submitted edBy(P
ri
ICS ° Pauth.�ori ,e
d Agent ❑Owner
ame :
Signature of Applicant:
Bate: 3C/a a
STATE OF NEW YORK)
COUNTY OF
being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above nark d,
(S)he is the
(Contractor,Agent,Corporate Officer,etc.)
of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this
application;that all statements contained in this application are true to the best of his/her owledge and belief-and.
that the work will be performed in the manner set.forth in the application file there t . H.T'AN=
BARBARA
Notary Public,State Of New York
Sworn before me this No. IDITA6086001,
Suffolk County,
day of 20aa k Commission iExpl 01/13/20
Notary Public
(Where the applicant is not the owner)
I,
,residing at ` `` Iw
old
�Mq(do hereby authorize AMP ARCHITECTURE to apply on
Wtoof Southold Building Department for approval as described herein.
��ture ate
t dALVlt-
Print
Owner's Name
2
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